Ramblings of an Emergency Physician in Texas

How can we practice for a mass casualty incident (MCI) if we believe “it couldn’t happen to me”?

While in San Francisco I had the chance to speak with Dr. Jacob Or, the president of the Israeli Association of Emergency Medicine, on a couple of occasions. He also happens to be an emergency physician at the largest trauma center in the Middle East. During a presentation he gave on the state of emergency medicine in Israel, Dr. Or couldn’t help but comment on how excellently well-prepared his men and women were for a mass casualty incident. Their surge capacity, apparently, is the stuff of legend, and it’s all been tested and proven. There was an upspoken current that the U.S. had a lot to learn from this small nation in this regard. Undoubtedly.

But I had a question, so I met up with Dr. Or after the talk over a beer. What about the docs in Iowa? In Peoria? What about the docs who want to improve surge capacity and disaster preparedness, but for whom an MCI simply isn’t a daily reality? How can we make disaster preparedness a reality for the EPs in the States who don’t see an impending threat of any kind?

“That’s the million dollar question” another doc chimed in.

The response I heard from Dr. Or and others was this: Focus on legitimate regional threats. If your town is near an oil refinery, base your mass casualty drill on a disaster at the plant, not a bomb at the mall. If you practice in Florida, your MCI should involve a hurricane rather than a terrorist attack.

Makes sense and it’s good logic, but it only partially satisfied me, so I want to know what people think. Have you experienced a mass casualty drill that was either particularly effective or ineffective? In your experience, what efforts were taken to get participants mentally invested in the drill? How can we make mass casualty drills more meaningful, and more effective in the long term?

This blue sky question is part of the reason that more than a thousand emergency physicians gathered in San Francisco this week. Every country is at a different stage of EM development, but some have a relatively clean slate to work with. Take Dr. Jim Holliman for instance, the man in charge of EM development in the entire country of Afghanistan. Not only does Dr. Holliman have the chance to help a country start fresh with their EM strategy, he’s here at ICEM hearing lessons-learned from more than 60 country delegates. In theory, someone like Holliman should be able to pick and choose the best elements of every system. Of course, that’s putting it way too simply (particularly considering the physical danger inherent in many regions), but it brings up an interesting question that I’d like to pose to the blogosphere: If you were designing an EM system from the ground up, what are some specific elements from the American system that you would keep and what would you toss out like old garbage? And remember, we’re talking about a clean slate. The sky’s the limit.

Long waits have become so typical in the ED that it seems cliche to even mention them. But it’s still a serious problem. The average for a patient in the U.S. is something abysmal, but I don’t even want to ask about the maximum wait. I’m guessing you’d measure it in days, not hours. And until today, I assumed that any solution to this problem would have to be a bottom-up approach, not mandated from on high. However, I had the chance to have a few words with Dr. Edward Glucksman, the emergency physician in charge of international emergency medicine in the United Kingdom, and what he told me shed new light on the issue.

According to Dr. Glucksman, a few years ago, Tony Blair’s government made a bold, seemingly over-reaching claim. They stated to the public that after a finite period of reforms initiated by the government, no one in the ED would wait more than 4 hours to be in a bed or sent home. Ever. This statement set off a series of extensive studies into what exactly caused wait times in the UK and how hospitals could attempt to meet this goal. According to Glucksman, the mandate actually put heat on hospitals and administrators in a way that physicians had been unable, and progress started to be made. Now, a few years out, 98% of all ED patients in the UK are in a bed or out the door in under 4 hours. That’s the max, mind you, not the mean. Now don’t get me wrong, I don’t want the federal government micromanaging the ED any more than the next guy, but this certainly got me thinking outside the box…

This morning I had the privilege of sitting down for breakfast with Dr. Kumar Alagappan, one of the key voices (some would say THE key voice) in the movement to get emergency medicine officially recognized in India. Dr. Alagappan, an EP currently practicing in New York City, is a generous, down-to-earth doc who has travelled extensively on his own dime to help make this amazing movement in India a reality. More on this interview soon…

Apparently, international emergency medicine isn’t for the faint of heart. And I’m not talking about CHF. You’ve gotta have guts. I found it interesting to learn that the greatest risk in practicing international emergency medicine is not that one might catch a communicable disease, but that one might die of physical violence. This according to Dr. Hilarie Cranmer, Clinical Instructor, Division of International Health and Humanitarian Programs at Brigham and Women’s Hospital in Boston. In fact, physical violence against humanitarian workers is on the rise, and it is increasingly targeted and intentional. The red cross, which was once a symbol of protection, has become, for many, a target.

“We all want to save the world,” said Cranmer, “but you’re at great risk for doing so.”

Then again, emergency medicine isn’t a specialty for the risk-averse. I look around and see a lot of men and women ready and equipped for the challenge.

First of all, a special thanks to GruntDoc for allowing me to host the blog this week while I attend the ICEM conference in San Francisco. A short travel story, without which any conference coverage would be incomplete. My wife and I arrived in the Bay Area last night after an uneventful flight and then promptly hopped into the cab from hell. Our driver looked sweet enough as we climbed in the car, but then we discovered that his right foot was made entirely of lead. He hurled through highway traffic at 90 mph. I kid you not. 90. In traffic. Let’s just say I’ll have to leave my scenic viewing of the Golden Gate Bridge to another ride.

But on to the show. ICEM is put on in coordination with the International Federation of Emergency Medicine (IFEM), a group which began as a small collection of countries with highly developed EM systems, but which has exploded in recent years. The meeting rotates through member countries, and the landmark international gathering will not take place in the United States again for at least 14 years. The conference will celebrate a year of unprecedented progress in the advancement of emergency medicine around the globe, such as in India where the specialty has finally made serious inroads thanks to the efforts of a little group of physicians called the American Association for Emergency Medicine in India (AAEMI). I have no doubt that the EM developments around the world will have far-reaching affects on the specialty in the United States.